Lecture 8/Chapter 7 Flashcards
Learning objectives
- outpatient, ambulatory, and primary care
- principles behind patient-centered medical homes and community based primary care
- reasons for dramatic growth in outpatient services
- various types of outpatient settings and services
- role of complementary and alternative medicine
- primary care delivery in other countries
- impact of ACA on primary care
outpatient and primary care services
- the terms outpatient and ambulatory are used interchangeably
- hospitals provided majority of outpatient care
- independent providers faced capital constraints
- consumer demand fueled growth of complementary and alternative medicine
- ACA addresses access for poor and vulnerable
what is outpatient care***
- outpatient services or ambulatory care
- does not require an overnight stay incurring room and boards cost
- ambulatory care similar to community medicine because it serves:
- surrounding community
- convenience
- accessibility
- the most basic outpatient services are physicals and minor treatment in physician office
ambulatory care
- diagnostic and therapeutic services for the walking patient
- used synonymously with community medicine
- moving yourself
- ambulatory care similar to community medicine because it serves:
- surrounding community
- convenience
- accessibility
outpatient services
- services not provided with an overnight stay
- great growth in outpatient care
- new settings, types, ownership, services
- physical exams
- minor treatment
- advanced outpatient in a hospital base setting
- physical exams and minor treatment are the most basic services
scope of outpatient services
- primary care is the foundation for ambulatory health services
- services other than primary care are an integral part of outpatient services
- technological advances allow treatments to be provided in ambulatory care settings
- hospital inpatient services continues to decline since 1980s
- executives see ambulatory care as an essential, no longer a supplemental service line
- hospital survival can depend heavily on ambulatory care*
- competition from health health agencies, ambulatory care, urgent care, outpatient surgery
primary care
- the foundation for ambulatory care
- plays a central role in a health care delivery system
- foundation of ambulatory care
- all primary care is outpatient, but not all outpatient care is primary care* -> emergency room, urgent care treatment, outpatient surgery, rehabilitation, renal dialysis, chemotherapy
- distinguished from secondary and tertiary care by duration, frequency, and intensity
- secondary and tertiary care are more complex and specialized
secondary care
- usually short term
- sporadic consultation from a specialist
- includes hospitalization
- routine surgery
- specialty consultation
- rehabilitation
tertiary care
- most complex level of care
- uncommon conditions
- institution based
- highly specialized
- technology driven
- rendered in large teaching hospitals
health care service frequency
- primary care- 75-85% of population requires only primary care
- secondary care- 10-12% requires referral to short term secondary care
- tertiary care- 5-10% require tertiary care
world health organization definition of primary health care
- world health organization (WHO, 1978)
- essential health care based on scientific acceptable methods
- universally accessibly and acceptable
- at an affordable cost
- to maintain at every developmental stage
- first level of contact*
- bringing health care as close as possible to where people live and work
- as part of a continuing health care process
institute of medicine definition
- IOM define primary care
- comprehensively addresses any health problem at any stage of patients life
- coordination ensures a combination of health services to best meet the patients needs
- continuity of care administered over time
- emphasizes accessibility and accountability
primary care and the ACA
- four primary care provisions:
- increased medicare and medicaid payments
- new incentives for primary care providers working in underserved areas
- expansion of the health center program and strengthening of the capacity of health centers
- creation of additional training programs
patient centered medical homes (PCMH)
- team oriented approach for special needs children requiring constant care coordination
- initially consisted of an interdisciplinary team of physicians and allied health professionals
- studies demonstrated a positive impact
- PCMH assessment tools
community oriented primary care elements
- reducing exclusion and social disparities
- organizing health services around peoples needs
- integrating health into all sectors
- pursuing collaborative models of policy dialogue
- increasing stakeholder participation
primary care providers: US primary care practitioners
- are not restricted to physicians trained in general and family practice
- includes internal medicine, pediatrics, and obstetrics and gynecology
primary care providers: nonphysician practitioners (NPPs)
-nurse practitioners (NPs), physician assistants (PAs), and certified nurse-midwives (CNMs)
growth in outpatient services
- reimbursement
- technological factors
- utilization control factors
- physician practice factors
- social factors
types of outpatient care settings and methods of delivery
- private practice
- hospital based services
- freestanding facilities
- retail clinics
- mobile medical, diagnostic, and screenings
- home health care
- hospice services
- ambulatory long term care services
- public health services
- community health centers
- free clinics
- other clinic
- telephone access
hospital-based services
- clinical services
- surgical services
- emergency services
- home health care
- womens services
- urgent care
freestanding facilities
- walk in clinics
- urgent care centers
- surgicenters
- preferred by patients
mobile medical, diagnostic, and screenings
-EMTs and paramedics
hospice services
- comprehensive services for terminally ill with life expectance of 6 months or less
- staffing on 24 hours basis
- medical and nursing care
- access to inpatient care
- social services and support
- therapy and access to supplies
- Two areas of emphasis:
- palliation (pain management) with psychosocial and spiritual support
- specific conditions for medicare certification
which of the following had the greatest impact on increasing the QUALITY of health care
- licensing healthcare professionals- improves quality of care
- medical insurance- improves access
- government pensions- improved quality of life not healthcare
- technology- improves quality of care
greatest impact on increasing the cost of health care
-technology
ambulatory long term care services
- nursing homes
- case management -> coordination and referral and finding the most appropriate care
- adult day health care
three characteristics of free clinics
- services provided at no charge or nominal charge
- clinic not directly supported or operated by a government agency
- services delivered by trained volunteer staff
complementary and alternative medicine (CAM): reasons for CAM growth
- most seek CAM therapies following Western treatments that have not helped
- want to avoid/delay complex surgeries or toxic allopathic treatments
- feel in control when empowered with medical and health related information
- want practitioners to take time to listen to them
complementary and alternative medicine (CAM): national center for complementary and alternative medicines (NCCAM) objectives
- explore complementary and alternative healing practices in the context of rigorous science
- train complementary and alternative medicine researchers
- disseminate authoritative information to the public and professionals
ambulatory
- you can move yourself
- walk in patients
visits to physicians
- physicians in general and family practice (22.8%)
- physicians in internal medicine (13.6%)
- pediatrics (11.1%)
- obstetrics and gynecology (6.4%)
- doctors of osteopathy (6.7%)
primary care in united kingdom
-most comprehensive coverage with little or no patient cost sharing
primary care in canada
-covers physicians visits but medication coverage varies
primary care in australia, new zealand, and germany
-varying degrees of cost sharing
Australia, Canada, France, Germany, Switzerland, and the U.S.
- payers typically use fee-for-service payments
- employ performance incentives
sweden and iceland
-all places mentions were mostly privatized except iceland and sweden
summary
- ambulatory services increased outside the hospital setting
- ambulatory services transcend basic and routine primary care services
- primary care has become specialized
- numerous outpatient services have emerged
- a variety of setting for services have developed
three elements for understanding primary care
- point of entry
- coordination of care
- essential care
- WHO definition
point of entry
- into the health care system where health care is organized around primary care
- the first contact a patient makes with the delivery system*
- role of a gatekeeper*: patient cannot see a specialist or be admitted without a physician referral
- goal: bring it as close to the population as possible
point of entry
- into the health care system where health care is organized around primary care
- the first contact a patient makes with the delivery system
- role of a gatekeeper: patient cannot see a specialist or be admitted without a physician referral
- goal: bring it as close to the population as possible
coordination of care
- to coordinate health care between patient and the many delivery component of the system
- primary care professional serve as advisors, advocates, gatekeepers
- meant to ensure continuity and comprehensiveness**
- countries geared to primary care have better health levels, satisfaction and lower expenses
- primary care helps mitigate the adverse health effects of income inequality
essential care
-primary health care is regarded as essential health care
goal of primary care
- to optimize population health
- disparities must be minimized to ensure equal care*
integrated primary care
-comprehensiveness, coordinated, continuous, seamless
comprehensiveness in primary care**
addresses any health problem at any stage of a persons life cycle
accessibility in primary care
-ease that a patient can interact with a clinician for any health problem
accountability in primary care
- clinical system:
- to provide quality care, patient satisfaction, use of resources efficiently, behaving ethically
- patient:
- responsible for own health that they can influence
- judicious use of resources
growth in outpatient services
- reimbursement
- technological factors
- utilization control factors
- physician practice factors
- social factors
reasons for outpatient growth: changes in reimbursement
- constraining inpatient services
- favoring outpatient services
- more reimbursement for outpatients services
- incentives outpatient to make hospitals less crowded -> better care for everyone
- costs less for the insurer!
reasons for outpatient growth: fewer payment restrictions
- surgery, dialysis, chemotherapy
- paid as fee-for-service
reasons for outpatient growth: development of new technology
- less invasive procedure -> recovery is short and you can leave same day
- quicker recuperation from surgery
- pain management -> recover at home
reasons for outpatient growth: utilization controls
- managed care restriction on utilization, quicker discharge
- prior authorization (precertification)
- utilization review
- list of hospitals that you are covered for
reasons for outpatient growth: social factors
- preference for obtaining services at home or in community based setting, especially long term care
- more nurturing environment to recover in
- youre not just a number
1980-1995- increase in total surgeries performed in outpatient departments
- internet
- EHR
- technology in general
home health
- services brought into the home
- nursing care
- medication monitoring
- bathing
- short term rehab (PT, OT, ST)
- homemaker service, transportation, medical equip, chores
- DME- durable medical equipment -> wheelchairs, oxygen, beds, walkers, commodes
- alternative would be institutionalization
ambulatory long term care services
- nursing homes
- case management
- coordination and referral
- finding the most appropriate care
- adult day health care
public health service
- immunization to a full range of inpatient and outpatient services
- from preventive service to treatment
public and voluntary clinics
- community health centers
- free clinics
- other clinics
coordinating in primary care
-combining health services to best meet the patients needs
continuity in primary care
-care over time
